Mass Casualty Triage Research Articles

Factors affecting the accuracy of prehospital triage application and prehospital scene time in simulated mass casualty incidents

BackgroundThe contemporary management of mass casualty incidents (MCIs) relies on the effective application of predetermined, dedicated response plans based on current best evidence. Currently, there is limited evidence regarding the factors influencing the accuracy of first responders (FRs) in applying the START protocol and the associated prehospital times during the response to MCIs. The objective of this study was to investigate factors affecting FRs’ accuracy in performing prehospital triage in a series of simulated mass casualty exercises. Secondly, we assessed factors affecting triage-to-scene exit time in the same series of exercises.MethodsThis retrospective study focused on simulated casualties in a series of simulated MCIs Full Scale Exercises. START triage was the triage method of choice. For each Full-Scale Exercise (FSEx), collected data included exercise and casualty-related information, simulated casualty vital parameters, simulated casualty anatomic lesions, scenario management times, and responder experience.ResultsAmong the 1090 casualties included in the primary analysis, 912 (83.6%) were correctly triaged, 137 (12.6%) were overtriaged, and 41 (3.7%) were undertriaged. The multinomial regression model indicated that increasing heart rate (RRR = 1.012, p = 0.008), H-AIS (RRR = 1.532, p < 0.001), and thorax AIS (T-AIS) (RRR = 1.344, p = 0.007), and lower ISS (RRR = 0.957, p = 0.042) were independently associated with overtriage. Undertriage was significantly associated with increasing systolic blood pressure (RRR = 1.013, p = 0.005), AVPU class (RRR = 3.104 per class increase), and A-AIS (RRR = 1.290, p = 0.035). The model investigating the factors associated with triage-to-scene departure time showed that the assigned prehospital triage code red (TR = 0.841, p = 0.002), expert providers (TR = 0.909, p = 0.015), and higher peripheral oxygen saturation (TR = 0.998, p < 0.001) were associated with a reduction in triage-to-scene departure time. Conversely, increasing ISS was associated with a longer triage-to-scene departure time (TR = 1.004, 0.017).ConclusionsUnderstanding the predictors influencing triage and scene management decision-making by healthcare professionals responding to a mass casualty may facilitate the development of tailored training pathways regarding mass casualty triage and scene management.

Evaluation of a new prehospital major incident triage tool: Informing current UK practice

During mass casualty incidents, the first Ambulance responders on scene face critical decisions about who receives medical treatment first. Effective clinical management of such incidents relies on triage, which prioritises patients based on injury severity, available resources, and the number of casualties. Various decision-making tools have been developed to assist emergency responders with triage decisions. However, there have been concerns raised about the efficacy of existing triage tools, which led to the development of a new pre-hospital triage tool for major incidents. The current study evaluated two versions of the new tool alongside the existing one used by UK emergency responders through a live exercise simulating two different major incidents. Participants offered valuable insights for the tools enhancement, notably in managing non-injured casualties and paediatric patients, and reducing cognitive load when making decisions. These findings shaped the final version of the new tool, deployed to UK Ambulance responders in Spring 2023. Findings demonstrate the importance of considering the visual presentation of triage tools as well as the inclusion of accurate physiological parameters to facilitate responder decision-making when categorising patients in mass casualty triage. Practical implications and suggestions for future research are discussed.

Utilization of an Asynchronous Online Learning Module Followed by Simulated Scenario to Train Emergency Medicine Residents in Mass-Casualty Triage.

This is a combined independent study and simulation session designed to teach and drill Mass Casualty Incident (MCI) Triage and is intended for emergency medicine residents at all levels. The training of emergency medicine residents to assume leadership roles in disaster response is important. However, lack of accepted specific educational goals on the national level leads to significant variability between residencies. The purpose of this session is to train EM residents in the use of the Simple Triage and Rapid Treatment (START) and pediatric JumpSTART algorithms for triage in mass casualty incidents (MCIs) using an asynchronous model. By the end of this small group session, learners will be able to: 1) describe START triage for adult MCI victims; 2) describe JumpSTART triage for pediatric MCI victims; 3) demonstrate the ability to apply the START and JumpSTART triage algorithms in a self-directed learning environment; 4) demonstrate the ability to apply the START and JumpSTART triage algorithms in a simulated mass casualty scenario under time constraints; and 5) demonstrate appropriate use of acute life-saving interventions as dictated by the START and JumpSTART triage algorithms in a high-pressure simulated environment. This session utilizes an online independent study module that was created de novo for this specific purpose by the authors followed by a high-pressure in-person simulation session where learners practice applying the START triage model with multiple simulated patients under time constraint. Learner feedback was collected after completion of the session. Retention of learning objectives was tested at four months via multiple-choice quiz. The session was very well received by our residents, who appreciated the opportunity to practice applying START triage under pressure. The average score on the pretest was 49%. Response rates to the post-test were low, but residents scored an average of 73%, indicating a trend towards retention of learning objectives. Overall, the utilization of a de novo online learning module followed by simulation proved to be a well-received method of teaching MCI triage to emergency medicine residents. We consider this to be an effective way to train MCI Triage with minimal in-conference time utilization. We plan to implement this training annually to provide our residents with longitudinal reinforcement of this vital skill. Mass casualty, MCI, triage, START triage, JumpSTART Triage, disaster, disaster preparedness, disaster curriculum, prehospital, EMS.

Development and Evaluation of an Immersive Cinematic Escape Room for Disaster Preparedness and Self-Efficacy Among Nurses

BackgroundThe occurrence of natural disasters is unpredictable. Nurses need to have the core competency of disaster nursing to effectively respond to natural disasters. This study aimed to develop and evaluate the effectiveness of an immersive cinematic escape room (ICER) instructional approach in disaster preparedness and self-efficacy in nurses. MethodThis quasi-experimental research design used a convenience sample of 115 nurses. The course contents covered establishment of medical stations, incident command system (ICS), personal preparedness and protection in disasters, and mass casualty triage (START). Evaluation of disaster preparedness and self-efficacy occurred before, one week after and four weeks after the course. ResultsThe experimental group, lacking prior disaster preparedness education experiences, demonstrated a statistically significant improvement (p < .01) compared to the control group with more such experiences. At week four, both groups showed improvement in the self-efficacy scores, but the improvement did not achieve statistical significance (p > .05). ConclusionThe ICER approach significantly enhanced nurses’ disaster preparedness and self-efficacy. Educators are encouraged to adopt this approach for comprehensive disaster nursing education.

START Triage Sebagai Istrumen Penanganan Korban dalam Setting Bencana

Unexpected incidents that result in significant loss or destruction are called disasters. In general, this event is closely associated with natural phenomena. Ultimately, though, this is frequently linked to incidents brought about by human intervention that entail drastic lifestyle modifications and significant harm. Since it is vital to allocate comparatively few resources to specific, urgent medical needs, triage is a crucial component of contemporary medical treatment. When a patient's medical demands and the resources that are available are not met in a timely or convenient manner, this task becomes critical. The foundation of Simple Triage and Rapid Treatment (START) is a quick evaluation of mental status, breathing, and perfusion (RPM). This work was written using a literature study methodology. Reference books (textbooks), scientific journals, and other pertinent sources provide the literature that is used. According to calibration and discrimination data, RPM (STARt triage) is a more reliable indicator of the blunt trauma survival rate than the Trauma Severity Score and the Revised Trauma Score. SALT triage is inferior to START (SMART) triage. On the other hand, employing START triage has been shown to increase time efficiency. It has been scientifically demonstrated that using START triage can result in suitable assessments for disaster management. Through the development of the Mass Casualty Triage Pack (SMART Triage Pack), STRAT triage has been used to enhance its efficacy.

Comparative Analysis of META and SALT Disaster Triage in an Adult Trauma Population: A Retrospective Observational Study.

Medical professionals can use mass-casualty triage systems to assist them in prioritizing patients from mass-casualty incidents (MCIs). Correct triaging of victims will increase their chances of survival. Determining the triage system that has the best performance has proven to be a difficult question to answer. The Advanced Prehospital Triage Model (Modelo Extrahospitalario de Triaje Avanzado; META) and Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT) algorithms are the most recent triage techniques to be published. The present study aimed to evaluate the META and SALT algorithms' performance and statistical agreement with various standards. The secondary objective was to determine whether these two MCI triage systems predicted patient outcomes, such as mortality, length-of-stay, and intensive care unit (ICU) admission. This retrospective study used patient data from the trauma registry of an American College of Surgeons Level 1 trauma center, from January 1, 2018 through December 31, 2020. The sensitivity, specificity, and statistical agreement of the META and SALT triage systems to various standards (Revised Trauma Score [RTS]/Sort Triage, Injury Severity Score [ISS], and Lerner criteria) when applied using trauma patients. Statistical analysis was used to assess the relationship between each triage category and the secondary outcomes. A total of 3,097 cases were included in the study. Using Sort triage as the standard, SALT and META showed much higher sensitivity and specificity in the Immediate category than for Delayed (Immediate sensitivity META 91.5%, SALT 94.9%; specificity 60.8%, 72.7% versus Delayed sensitivity 28.9%, 1.3%; specificity 42.4%, 28.9%). With the Lerner criteria, in the Immediate category, META had higher sensitivity (77.1%, SALT 68.6%) but lower specificity (61.1%) than SALT (71.8%). For the Delayed category, SALT showed higher sensitivity (META 61.4%, SALT 72.2%), but lower specificity (META 75.1%, SALT 67.2%). Both systems showed a positive, though modest, correlation with ISS. For SALT and META, triaged Immediate patients tended to have higher mortality and longer ICU and hospital lengths-of-stay. Both META and SALT triage appear to be more accurate with Immediate category patients, as opposed to Delayed category patients. With both systems, patients triaged as Immediate have higher mortality and longer lengths-of-stay when compared to Delayed patients. Further research can help refine MCI triage systems and improve accuracy.

Emergency Nurse Roles, Challenges, and Preparedness in Hospitals in the Context of Armed Conflict.

An understanding of emergency nurses' roles, challenges, and preparedness in the context of armed conflict is necessary to capture in-depth insights into this specialty and their preparational needs when working in these unique environments. Unfortunately, the evidence about emergency nurses' work in the context of armed conflict is scant. Semi-structured interviews were conducted with 23 participants and analyzed using qualitative content analysis. The COREQ guideline for reporting qualitative research was followed. The emergency nurses' roles, challenges, and preparedness in hospitals in the context of armed conflict were explored in detail. The main challenges that these nurses faced included poor orientation, access block, and communication barriers. Various perspectives about preparation, including education, training, and strategies for preparing emergency nurses were identified. The most striking findings in these settings were the diversity of armed conflict injuries, clinical profiles of patients, triage of mass casualties, trauma care, surge capacity, orientation, communication, and strategies for preparing nurses. This study provided an exploration of the scope of emergency nurses' roles, and how they were prepared and expected to function across multiple hospitals in armed conflict areas. The resultant snapshot of their experiences, challenges, and responsibilities provides an informative resource and outlines essential information for future emergency nursing workforce preparedness. There is a broad range of preparational courses being undertaken by emergency nurses to work effectively in settings of armed conflict; however, required education and training should be carefully planned according to their actual roles and responsibilities in these settings.

Doctors with Borders

This paper presents the real case of a military surgeon who is the only one working at a small hospital in Iraq. The military surgeon can only operate on one wounded soldier due to limited medical resources. The first wounded soldier to arrive is the enemy. The second wounded soldier to arrive shortly after the enemy is a compatriot. Both soldiers will die without lifesaving surgery. The military surgeon is ordered by his superior not to operate on the enemy. Under the Geneva Conventions, physician-soldiers are legally required to give medical attention impartially. The only exception is urgent medical need. Both soldiers, friend and foe, have an urgent medical need. Dual-loyalty dilemmas such as this one can arise for military medical practitioners when loyalty to patients comes into conflict with loyalty to third parties such as the state. In this paper, several solutions to the dual-loyalty dilemma are considered and rejected. Solutions to the dual-loyalty dilemma ultimate fail because they rest on the physician-as-healer model which grounds contemporary medical ethics. The view that the ultimate objective of physicians and medicine is winning battles is defended. Physicians are non-neutral and partial fighters who sometimes must do harm. Medicine is a weapon that physicians use to fight an enemy. The only relevant differences between a soldier and physician are the kind of enemy, location of the enemy, and the type of weapons used against the enemy. The paper concludes that physician-soldiers are doctors with borders. There is no dual-loyalty dilemma on the physician-as-fighter model. The military surgeon should obey his orders and not operate on the enemy. Implications of the physician-as-fighter model for mass casualty triage and physician-soldier participation in non-lethal weapons development are considered.

Optimizing Mass Casualty Triage: Using Discrete Event Simulation to Minimize Time to Resuscitation.

Urban areas in the US are increasingly focused on mass casualty incident (MCI) response. We simulated prehospital triage scenarios and hypothesized that using hospital-based blood product inventories for on-scene triage decisions would minimize time to treatment. Discrete event simulations modeled MCI casualty injury and patient flow after a simulated blast event in Boston, MA. Casualties were divided into moderate (Injury Severity Score 9 to 15) and severe (Injury Severity Score >15) based on injury patterns. Blood product inventories were collected from all hospitals (n = 6). The primary endpoint was the proportion of casualties managed with 1:1:1 balanced resuscitation in a target timeframe (moderate, 3.5 U red blood cells in 6 hours; severe, 10 U red blood cells in 1 hour). Three triage scenarios were compared, including unimpeded casualty movement to proximate hospitals (Nearest), equal distribution among hospitals (Equal), and blood product inventory-based triage (Supply-Guided). Simulated MCIs generated a mean ± SD of 302 ± 7 casualties, including 57 ± 2 moderate and 15 ± 2 severe casualties. Nearest triage resulted in significantly fewer overall casualties treated in the target time (55% vs Equal 86% vs Supply-Guided 91%, p < 0.001). These differences were principally due to fewer moderate casualties treated, but there was no difference among strategies for severe casualties. In this simulation study comparing different triage strategies, including one based on actual blood product inventories, nearest hospital triage was inferior to equal distribution or a Supply-Guided strategy. Disaster response leaders in US urban areas should consider modeling different MCI scenarios and casualty numbers to determine optimal triage strategies for their area given hospital numbers and blood product availability.

Mass casualty triage: using virtual reality in hazardous area response teams training

Background: In recent years, virtual reality (VR) has become a pedagogic resource that complements the general training health professionals receive. VR could revolutionise hazardous area response team (HART) mass casualty incident (MCI) triage training. Aims: The study aimed to establish whether VR could improve the overall effectiveness of HART triage training and increase practitioner confidence and preparedness for an MCI. Methods: The author co-developed a VR marauding terrorist attack (MTA) triage scenario at a football stadium. The software was loaded onto Oculus Quest 2 VR headsets. HART paramedic participants completed an online survey before the exercise, which focused on demographics and experience. They were then familiarised with the VR equipment, which incorporated a tutorial on patient interaction. This was followed by a VR MTA exercise with 15 casualties, after which they completed an online survey to gauge their opinions. Results: All 36 HART paramedics recruited agreed VR would improve the effectiveness of HART paramedic training for mass casualty triage. Furthermore, 30 (83%) agreed that VR was more effective than the sand manikins currently used in training. Following the VR scenario, 31 (86%) of participants reported increased confidence in responding to an MCI and carrying out mass casualty triage. Conclusion: VR can improve the effectiveness of the HART triage training and may increase HART paramedic confidence in responding to an MCI and carrying out primary triage. Further studies with larger samples could determine if the results from this study can be generalisable across all frontline paramedic clinicians. Additionally, participant accuracy and time on task data should be evaluated.

Prehospital Lessons From the War inUkraine: Damage Control Resuscitation andSurgery Experiences From Point of Injury to Role 2.

The ongoing war in Ukraine presents unique challenges to prehospital medical care for wounded combatants and civilians. The purpose of this article is to identify, describe, and address gaps in prehospital care, casualty evacuation, and medical evacuation throughout Ukraine to share lessons for other providers. Observations and experiences of medical personnel were collected and analyzed, focusing on pain management, antibiotic use, patient assessment, mass casualty triage, blood loss, hypothermia, transport immobilization, and clinical governance. Gaps identified include limited access to pain management, lack of antibiotic guidance, inadequate patient assessment and triage, access to damage control resuscitation and blood, challenged transport immobilization practices, and challenges with clinical governance for both local and foreign providers. Improved prehospital care and casualty and medical evacuation in Ukraine are required, through increased use of empiric pain management, focused antibiotic guidance, enhanced patient assessment and triage in the form of training, access to prehospital blood, and better transport immobilization practices. A robust and active lessons learned program, trauma data capture, and quality improvement process is needed to reduce preventable morbidity and mortality in the war zone. The recommendations presented in this article serve as a starting point for improvements in prehospital care in Ukraine with potential to change prehospital training for the NATO alliance and other organizations operating in similar areas of conflict. Graphical Abstract.

Knowledge Retention From Emergency Medicine Simulation-Based Learning Curriculum for Pre-clinical Medical Students.

Introduction Traditional medical school curricula rely on textbook-based learning during the first two years, often limiting students' clinical exposure. Simulation-based learning (SBL) provides an opportunity for students to gain clinical exposure and competency with common procedures as well as to gain knowledge related to common clinical topics. Retention of factual knowledge is a current topic of discussion as medical learners often have difficulty with long-term retention. The aim of this study was to assess if students would learn, retain, and enjoy emergency medicine (EM)-focused SBL. Materials and methods We developed an EM-focused SBL curriculum consisting of four main educational events: suturing, medical stabilization, mass casualty triage, and point-of-care ultrasound (POCUS). Participants were first- and second-year healthcare students enrolled in a traditional, preclinical curriculum, who completed pre- and post-event quizzes consisting of multiple-choice questions on topics covered during the SBL scenario. We compared pre- and post-event quiz scores using a one-way paired t-test. Quizzes were readministered up to 100 days after each SBL event to test knowledge retention, and scores were compared across time by repeated-measures analysis of variance (RMANOVA). Results For suture (n=22), mass casualty (n=20), and ultrasound simulations (n=17), post-event mean quiz scores increased significantly in comparison to mean quiz scores from before the event (p≤0.05). Medical stabilization simulation post-event scores were increased but did not reach statistical significance. Data collected at 45, 74, and 94 days following the suture lab as well as 29 and 49 days after the medical evacuation event, and 20 days after the mass casualty event showed no statistical decrease in quiz means suggesting retention of knowledge amonglearners. Subjective assessments of participant satisfaction demonstrated an enjoyment of the events. Discussion EM-focused SBL events offered enjoyable learning opportunities for students to effectively obtain and possibly retain clinical knowledge. Conclusion SBL has the potential to improve student retention of clinical knowledge during the preclinical years and, therefore, should be further explored and implemented as a core pillar of medical education as opposed to its current state as a learning adjunct.

An assessment of mass casualty triage systems using the Alberta trauma registry.

Triage is the process of identifying patients with both the greatest clinical need and the greatest likelihood of benefit in the setting of limited clinical resources. The primary objective of this study was to assess the ability of formal mass casualty incident triage tools to identify patients requiring urgent lifesaving interventions. Data from the Alberta Trauma Registry (ATR) was used to assess seven triage tools: START, JumpSTART, SALT, RAMP, MPTT, BCDand MITT. Clinical data captured in the ATR was used to determine which triage category each of the seven tools would have applied to each patient. These categorizations were compared to a reference standard definition based on the patients' need for specific urgent lifesaving interventions. Of the 9448 records that were captured 8652 were included in our analysis. The most sensitive triage tool was MPTT, which demonstrated a sensitivity of 0.76 (0.75, 0.78). Four of the seven triage tools evaluated had sensitivities below 0.45. JumpSTART had the lowest sensitivity and the highest under-triage rate for pediatric patients. All the triage tools evaluated had a moderate to high positive predictive value (> 0.67) for patients who had experienced penetrating trauma. There was a wide range in the sensitivity of triage tools to identify patients requiring urgent lifesaving interventions. MPTT, BCD and MITT were the most sensitive triage tools assessed. All of the triage tools assessed should be employed with caution during mass casualty incidents as they may fail to identify a large proportion of patients requiring urgent lifesaving interventions.

Learning Mass Casualty Triage via Role Play Simulation

Learning Mass Casualty Triage via Role Play Simulation

The Training Effects of Mass Casualty Triage in Radiological Events for 119 Emergency Medical Team

Introduction:Korea Institute Radiological Medical Sciences operates an emergency medical response system in case of a radiological accident or disaster. A radiation accident or disaster can affect large-scale patients and destroy medical infrastructure. However, there is currently a lack of specialized education for treating large-scale patients or high-dose exposure patients. This study aimed to evaluate the efficiency of radiological mass casualty triage education programs and present a new training method to improve the ability of 119 emergency medical teams in the event of a radiological accident or disaster.Method:The results of mass casualty triage for radiological events were analyzed using the audience response system and questionnaire for paramedics who participated in the radiation accident response training program. For 25 paramedics, a pre-post evaluation was conducted on two items: understanding the mass triage and understanding the radiological mass triage. The data were analyzed using the SPSS WIN 23.0 program.Results:Thirty simulated patient scenarios were developed with the addition of clinical symptoms of radiation exposure based on the four trauma classifications: immediate, urgent, delayed, and death. The triage results of 30 cases conducted by 119 emergency medical teams were evaluated, and the trainees were asked to respond to the level of improvement in their knowledge of triage through pre- and post-training questionnaires. As a result of the pre- and post-education questionnaire, the degree of understanding of the mass triage was 3.8 before education and 4.4 after education, showing a significant difference (p=.003/MAX=5). The pre- and post-education questionnaire results of radiological mass triage showed a difference between 2.3 before education and 4.1 after education (p=.000/MAX=5).Conclusion:For effective radiation medical response, 119 emergency medical teams are required to have a repetitive mass triage education program for radiological events. It is especially important to provide a radiological triage system for field application.

Mass Casualty Triage: What Works and Who Does it Best?

Introduction:There is a consensus that there lacks a standard for primary triage during mass casualty incidents. This is further compounded by a dearth of high quality research on the topic. Some studies suggest the superiority of SALT triage versus other triage systems, however, findings have not widely transitioned to clinical practice. We believe that despite specialized training including that in emergency medicine or emergency medical services (EMS), there will be significant variability amongst triage determination and use of triage methods. This study intends to analyze various provider skill levels and their accuracy of triage determination.Method:In a disaster exercise, a group of providers trained to use START triage were expected to triage, treat and determine transport order of the patients from a scenario of a simulated intentional radiological dispersal device (RDD) detonation with multiple casualties. Another group of providers trained to use SALT triage were expected to triage, treat, and determine transport order of patients from a scenario of a building collapse after a hurricane to assess SALT triage with the participating officers. Additional cohorts of EMS clinicians will be given the same case scenarios and asked to triage, treat when necessary, and determine transport order of the patients.Results:The initial data from the RDD exercise includes 102 patient case scenarios with 27 minimal (green), 40 delayed (yellow), and 35 immediate (red) patients. The providers involved in the exercise are trained at minimum to NREMT EMT level. Results showed an under-triage rate of 7.8%, an over-triage rate of 20.6% and overall accuracy of 71.6% when using START triage.Conclusion:The undertriage rate with START is 7.8% is higher than the generally acceptable rate of less than 5%. Our research is ongoing and we anticipate completion in 2023. We hope that our research provides future direction to improve triage in disaster scenarios.

Triage, Trauma, and Civil Unrest: Decreasing Critical Care Overcrowding and Nursing 'Undertriage' Praxes at the University of Gondar Public Hospital, Ethiopia

Introduction:In March of 2022, the Washington Post reported that the: “Deadliest war isn’t in Ukraine, it’s in Ethiopia.” Current death toll estimates are around 600,000: 50,000-100,000 (warfare); 150,000-200,000 (starvation), and 100,000 (lack of medical treatment). Due to increasing civil unrest, a mixed-methods study began at the University of Gondar Hospital in Gondar, Ethiopia. Between 2018-2022, the estimated (daily average) of patients was reported to have quadrupled, from 100 to 400. The global research team implemented 12 new systemic revisions in overcrowding, triage nursing praxes, and resuscitations. Patient data from 521 hospital records was evaluated, as well as resource allocation(s) in staffing, equipment, and training.Method:The study’s inclusion criteria for A&amp;E data included all patients who sought emergency care at UoG Teaching Hospital’s Emergency Department between May 13, 2018, and June 29, 2018, primarily during the normal daytime working hours between 9am and 2pm, as nighttime security and road travel were deemed less secure for data collectors.Results:After the 12-benchmark implementation, there was an approximate 15%-25% decrease in direct-from-triage ‘Red’ patient admission; congestion dropped 50%-70%; and the occurrences of successful resuscitations increased. The study revealed that over 75% of patients presented with symptoms indicative of illness(es), and 24.4% presented with trauma (remaining psychiatric). Of the trauma cases, approximately 28.3% were ‘intentional’ injuries. The patients’ mean TEWS triage score was 3.294, with a standard deviation from the mean of 1.9938.Conclusion:The overall prevalence of patients necessitating surgical evaluation, the elevated use of triage discriminators due to space, equipment, and staff concerns, and the predominant use of ‘Yellow Zone’ services–all pointed to the vital need for resource re-allocation(s), stricter ECCN adherences to TEWS triage indices, as well as future Mass Casualty Planning, Triage, and Response, and Mass Casualty Medical Operations training.

Rethinking Mass-Casualty Triage.

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A region-wide all-hazard training program for pre-hospital mass casualty incident management: a real-world case study.

We report the development, implementation and results of a sustainable region-wide mass-casualty management pre-hospital training program implemented by the Regione Lombardia emergency medical services (EMS) agency AREU in Italy. The educational program learning objectives are: 1) Command and control, communications and resource management. 2) Mass casualty triage and the START triage protocol. 3) On-scene management 4) Regione Lombardia and AREU Mass Casualty standard operating procedures 5) Inter-agency communications and relations. For each course edition data on participants summative assessment, participants feedback and costs were collected. Between June 26th,2013 and December 31st,2020 a total of 84 editions of the provider training event were delivered, training an overall 1329 prehospital providers. 1239 (93%) passed the summative assessment and were qualified as being operationally "ready". Regarding participants' feedback, the overall program was rated 4.4±0.7out of 5. The overall cost of running the provider program during the study period was € 321,510 (circa US$ 382,000). The average cost per edition was € 3,828 and € 242 per participant. We have described a simple yet interactive simulation and blended-learning approach, which has yielded good pass rates, good participant satisfaction and contained costs to systematically train emergency medical service personnel.

Mass Casualty Incident: Do Tactical Tag Bracelets Improve Triage Performance by First Responders? A Randomized Controlled Mass Casualty Incident Simulation and Response of A French Gendarmerie Elite Unit.

Tactical triage replaces primary triage in the exclusion zone in mass murder or terrorist events to prioritize victims requiring life-saving interventions (LSIs) and/or rapid extraction in an environment with a lack of resources and under active threat. French gendarmerie tactical unit medical teams use triage bracelets during mass casualty incidents (MCIs). This study assessed the value of these bracelets in the tactical triage performance of nonhealthcare combat rescue operators in an MCI simulation. To compare triage performance with and without the use of bracelets based on categorization accuracy, LSIs, and time to end triage. Two groups of operators were randomly assigned to participate in an MCI simulation alone (10 simulated patients) with (intervention group) or without (control) bracelets. The primary outcome was triage performance assessed by the mass casualty triage performance assessment tools. The results were measured based on the LSI required, triage category, and time of completion of the task. Secondary outcomes were operator-perceived stress and self-efficacy. Eleven operators (intervention group n = 5, control group n = 6) participated. Triage performance, based on a maximum score of 90, was better for the intervention group [72.200 (SD = 10.330) vs. 57.000 (SD = 12.961), P = .045]. Self-efficacy was increased after the simulation in the intervention group [45.00 47.2 (SD = 4.147) vs. 50.400 (SD = 5.505), P = .034)]. This is the first study to show the best triage performance among nonhealthcare combat rescuers using triage bracelets in an MCI simulation. The small sample size did not allow for external validity of the results. The initially calculated number of participants (N = 12) was not reached for operational reasons. The use of bracelets may have a place in the medico-organizational act of tactical triage during MCIs in exclusion zones. Further studies should be conducted to assess the value of triage bracelets by other first responders, including physician-nurse teams.